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Genius激光与传统手术治疗牙龈增生的术后反应与舒适度临床对比研究
甘祎1,2, 黄姣1,2, 白远亮2,3, 张芷玮2,3     
1. 400015 重庆,口腔疾病与生物医学重庆市重点实验室;
2. 400015 重庆,重庆医科大学附属口腔医院牙周科;
3. 400015 重庆,重庆市高校市级口腔生物医学工程重点实验室
[摘要] 目的 比较Genius激光(水冷型Nd:YAG激光)和手术刀两种方式行牙龈切除术和成形术术后患者的创口愈合情况及舒适度。方法 收集牙龈增生患者31例,共计172颗前牙,实验分为激光组和手术刀组,每组各86颗。分别收集术前、术后1周及术后2周的龈沟液(gingival crevicular fluid, GCF), 比较GCF量的变化及GCF中转化生长因子-β1(transforming growth factor-β1, TGF-β1) 和白细胞介素-1β(interleukin-1β, IL-1β)水平的变化,同时比较患者术前术后牙龈外形色泽、术后1周内的疼痛及出血情况。结果 术后1周2组GCF量无明显差异(P=0.091),术后2周GCF量在激光组较手术刀组低,且差异具有统计学意义(P=0.000)。术后1周及术后2周TGF-β1和IL-1β水平在激光组均较手术刀组低,且差异具有统计学意义(P=0.003,P=0.000;P=0.006,P=0.008)。术后第1天和第2天激光组疼痛均较手术刀组低,且差异具有统计学意义(P=0.008,P=0.006),从术后第3天开始2组无统计学差异(P=0.238)。激光组术后均未出血,手术刀组除术后第1天有3例出血外,其余均未出血。术后1周手术刀组牙龈较激光组红肿,术后2周手术刀组有23例患者的牙龈较激光组稍红肿。结论 Genius激光与手术刀比较具有术后创口愈合炎症反应低、创面愈合快和舒适度高的优势,可以作为临床医师行牙周软组织手术的优选方式。
[关键词] 牙龈增生     Nd:YAG激光     手术刀     龈沟液     转化生长因子-β1     白细胞介素-1β     创口愈合    
Comparison of postoperative reaction and comfort between Genius laser and traditional surgery for gingival hyperplasia
GAN Yi1,2 , HUANG Jiao1,2 , BAI Yuanliang2,3 , ZHANG Zhiwei2,3     
1. Chongqing Key Laboratory for Oral Diseases and Biomedical Sciences, Chongqing, 400015;
2. Department of Periodontics, Stomatological Hospital of Chongqing Medical University, Chongqing, 400015;
3. Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, 400015, China
Supported by the Project of Medical Scientific Research of Chongqing Municipal Health and Family Planning Commission (2015ZDXM018)
Corresponding author: HUANG Jiao, E-mail:huangiiao161108@163.com
[Abstract] Objective To compare the wound healing and comfort in the patients following gingivectomy and gingivoplasty via Genius laser and scalpel surgery. Methods A total of 31 patients (172 anterior teeth) treated in our hospital from May 2015 to April 2016 were enrolled in this study. The trial was divided into laser group and scalpel surgery group randomly, with each group including 86 teeth. Gingival crevicular fluid (GCF) samples were collected preoperatively, and in 1 and 2 weeks postoperatively. The contents of transforming growth factor-β1 (TGF-β1) and interleukin-1β (IL-1β) in the GCF, gingival morphology and color, postoperative pain and bleeding within 1 weeks after surgery were compared between the 2 groups. Results There was no difference in the amount of GCF between the 2 groups at 1 week postoperatively(P=0.091), but the amount of the laser group was significantly less in the laser group than the scalpel surgery group at 2 weeks (P=0.000). The GCF contents of TGF-β1 and IL-1β in the laser group were significantly lower than those in the scalpel surgery group at 1 and 2 weeks postoperatively (P=0.003, P=0.000; P=0.006, P=0.008). Postoperative pain was significantly milder in the laser group than the scalpel surgery group at the first day and second day (P=0.008, P=0.006), but no such difference was seen since the third day. And there was no bleeding case in the laser group, but there had 3 cases at the first day in the scalpel surgery group. At 1 week after operation, the gingival in all the patients of the scalpel surgery group was more swollen and red than the laser group, and in 2 weeks later, gingival swelling and redness were mildly severer in 23 cases of the surgical group than the laser group. Conclusion Genius laser is superior to conventional scalpel surgery in gingivectomy and gingivoplasty with respect to postoperative wound healing, inflammatory reaction and patient's comfort. Genius laser is a preferred option in periodontal surgery in clinical practice.
[Key words] gingival hyperplasia     Nd:YAG laser     scalpel     gingival crevicular fluid     transforming growth factor-β1     interleukin-1β     wound healing    

牙龈增生的患者经非手术治疗后,如仍不能完全消退者,常需采用牙龈切除术和牙龈成形术治疗。传统的牙龈切除、成形术是采用手术刀切除增生的牙龈组织,患者舒适度欠佳。较传统方式而言,激光具有术中出血较少、术后止血快、不需缝合等优点[1-4]

龈沟液(gingival crevicular fluid, GCF)及其龈沟液内炎症因子的测定可作为牙龈组织炎症程度的较客观的指标[5-6]。龈沟液内含有的细胞因子种类较多,白介素-1β(interleukin-1β, IL-1β)存在有炎症的牙龈组织和GCF中,可导致牙周组织的破坏[7-9]。PULIKKOTIL等[9-10]的研究表明IL-8可作为监测牙周翻瓣术后伤口愈合的重要指标。组织破坏可以由转化生长因子-β1(transforming growth factor-β1, TGF-β1) 抑制,且TGF-β1在伤口早期愈合中起着重要的作用[11]

有研究报道牙龈切除术后,牙龈创面在术后7~14 d已完全上皮化,但术后1个月仍有活跃的结缔组织修复[12]。此发现倾向于认为牙龈愈合是一缓慢的过程[13],已有学者运用局部药物来促进创面的愈合[14]。也有学者运用激光行牙龈切除术,但对于是否加速牙龈创面的愈合过程有不同的意见[15-18]。Genius激光,称水冷型钇铝石榴石晶体激光(water-cooled neodymium-doped yttrium aluminium garnet laser, Nd:YAG),又称水冷型Nd:YAG激光,本研究旨在研究Genius激光与传统的手术刀牙龈切除术、牙龈成形术患者术后创口愈合的炎症反应、创口愈合速度及舒适度的区别,为临床医师的选择提供一定的理论指导依据。

1 材料与方法 1.1 研究对象

选择2015年5月至2016年4月在重庆医科大学附属口腔医院牙周科(上清寺院区)治疗牙龈增生的患者31例,其中男性患者17例,女性患者14例,年龄10~27岁,一共纳入172颗前牙,手术刀组和激光组均有96颗。本研究获得重庆医科大学医学研究伦理委员会审批同意(2015),所有患者均签署基础治疗及手术知情同意书。

纳入标准:① 无系统性疾病;② 排除药物性牙龈增生;③ 女性未妊娠;④ 3个月内未服用抗生素;⑤ 经牙周基础治疗后牙龈增生未消退的前牙;⑥ 无临床附着丧失。

1.2 研究方法

1.2.1 手术方法

进行口腔卫生指导(oral hygiene instruction, OHI),全口基础治疗后1个月再评估,牙龈增生未消退者行牙龈切除术和牙龈成形术。采用随机自身对照方法,确定一侧为激光组(实验组),另一侧为手术刀组(对照组)。

激光组:Genius激光(Genius 9SDL, Denmark),调为“Gingivectomy”模式(功率4 W,喷雾:25 mL/min)。在距离牙龈组织1~2 mm处(无接触),用激光横扫大约45 s以麻醉需要切除的牙龈。此后,光纤直接与牙龈接触,采用横扫来回移动以切除牙龈,然后用Gracey刮治器刮除被切除的牙龈。

手术刀组:局麻下用牙周探针在牙龈表面标记袋底行外斜切口切除增生组织[19]。术毕,对患者强化OHI,要求患者术后1周内术区不能刷牙,0.12%氯己定含漱剂,每天2次,每次15 mL,含漱1 min。

1.2.2 龈沟液的收集[20]

编号含有30#吸潮纸尖的EP管称重记录。收集龈沟液:去除受试位点的软垢、棉球隔湿及气枪吹干,纸尖采集牙龈增生侧3个位点的龈沟液,留置60 s后取出,若纸尖被血或唾液污染则弃之,间隔60 s后,按照上述方法重取。EP管称重记录,然后立即加入200 μL PBS液(pH为8.4),置于-80 ℃冰箱内保存待检。

1.2.3 术后患者状态评估

术后1周内每天电话回访术者行问卷调查,评估两种术式的舒适度、是否出血及服用止痛药。将患者主观感受分为6级[21]:① 0级:无明显疼痛不适;② 1级:注意时有轻微不适但无明显疼痛;③ 2级:注意时痛感明显;④ 3级:不注意时出现疼痛不适但不影响正常生活;⑤ 4级:疼痛影响正常生活,但痛感能忍受;⑥ 5级:极痛不能忍受,严重影响正常生活。

术后1周和术后2周,患者复诊时观察其牙龈形态及水肿情况并记录。

1.2.4 龈沟液的测定

从-80 ℃冰箱内取出EP管,室温下解冻30 min,离心25 min(4 ℃,2 000 r/min)提取上清液,酶联免疫检测法(ELISA)测定TGF-β1和IL-1β的水平。

1.3 统计学方法

采用SPSS 18.0软件处理数据。分析龈沟液、TGF-β1和IL-1β数据,因为本研究数据不符合正态分布,故计量资料采用四分位数表示M(Q1, Q3),组间采用多样本间独立样本非参数检验,组内采用多样本间相关样本的非参数检验。患者术后疼痛度采用χ2检验。P < 0.05表明差异具有统计学意义。

2 结果 2.1 GCF量的变化

2组GCF量在术前和术后1周均没有统计学差异(P=0.963, P=0.091),但术后2周具有统计学差异(P=0.000)。见表 1

表 1 手术刀组和激光组龈沟液对比[M(Q1, Q3), 10-4g, n=86颗]
组别 术前 术后1周 术后2周
手术刀组 9.00(8.00, 11.00) 27.50(25.00, 30.00) 19.00(18.00, 22.00)
激光组 9.00(8.00, 11.00) 26.00(24.00, 29.00) 16.50(13.80, 19.32)
P 0.963 0.091 0.000

2.2 TGF-β1水平的变化

2组术前没有统计学差异(P=0.812),术后1周和术后2周均具有统计学差异(P=0.003, P=0.000),见表 2

表 2 手术刀组和激光组TGF-β1对比[M(Q1, Q3), pg/mL, n=86颗]
组别 术前 术后1周 术后2周
手术刀组 556.95(446.88, 693.58) 677.96(461.90, 769.61) 484.10(355.52, 576.18)
激光组 561.08(446.88, 693.58) 596.08(445.72, 638.72) 310.68(214.39, 401.28)
P 0.812 0.003 0.000

2.3 IL-1β水平的变化

2组术前没有统计学差异(P=0.871),术后1周和术后2周均有统计学差异(P=0.006, P=0.008),见表 3

表 3 手术刀组和激光组IL-1β对比[M(Q1, Q3), pg/mL, n=86颗]
组别 术前 术后1周 术后2周
手术刀组 24.36(19.83, 29.80) 45.43(30.22, 75.57) 30.64(23.74, 42.80)
激光组 24.36(20.23, 30.00) 39.69(31.10, 48.02) 25.72(17.87, 35.53)
P 0.087 0.006 0.008

2.4 术后疼痛情况

术后第1天和第2天激光组疼痛人数较手术组低,均具有统计学差异(P=0.008, P=0.006)。从术后第3天开始,两组无统计学差异(P=0.238)。见表 4

表 4 手术刀组和激光组术后1周内疼痛情况(例)
时间 0级 1级 2级 3级 P
第1天
手术刀组 10 12 5 4 0.008
激光组 21 9 1 0
第2天
手术刀组 19 10 2 0 0.006
激光组 29 2 0 0
第3天
手术刀组 28 3 0 0 0.238
激光组 31 0 0 0
第4~7天
手术刀组 31 0 0 0 -
激光组 31 0 0 0

2.5 术后出血情况

术后仅手术刀组在术后第1天有3例出血。

2.6 术前术后牙龈外形和色泽

术后2组外形区别不大。术后1周患者牙龈手术刀组明显较激光组红肿,术后2周,2组牙龈红肿普遍消退,但仍有23例手术刀组患者牙龈较激光组稍红肿。上前牙牙龈乳头稍显肥厚,右上区前牙牙龈用手术刀修整牙龈成形,左上区前牙牙龈用激光修整牙龈成形。术后1周右上区前牙龈较左上区红肿;术后2周上前牙区牙龈已基本消除水肿,但仍可见右上前牙区尖牙处牙龈稍红。

3 讨论

激光作用于生物组织时,具有生物刺激效应、光热效应、机械效应等,因而激光在牙周治疗领域发挥着越来越重要的作用。研究表明激光照射牙周组织,无论激光波长的长短,均可影响GCF及其所含的细胞因子的浓度水平,以及被照射组织的愈合速度[22]。GCF的量在术后2周,激光组明显低于手术刀组,表明激光组的炎性反应较低。2组术后2周GCF量均较术前多(P < 0.05),提示组织未完全愈合,仍存在炎性反应,与文献[12]所述相符。

在牙周病患者中,牙周组织和GCF中均能检测IL-1β,且IL-1β可以促进前列腺素E和基质金属蛋白酶的分泌,从而破坏牙周组织[8-9],而TGF-β1可促进组织的再生和重建[11],因而学者将IL-1β和TGF-β1作为判断牙周手术后组织是否愈合良好的指标[6, 9-11, 23]。本研究中,GCF的量、术后1周IL-1β与TGF-β1的浓度水平最高,术后第2周浓度水平仍高于术前,表明术后2周牙龈仍未完全愈合,但组织炎症已有所降低,与DAMANTE[15]的观点一致。激光组IL-1β和TGF-β1浓度水平在术后均较手术刀组低,表明激光行软组织手术后,其创口愈合速度较传统手术刀快。JENSEN等[18]运用水冷型Nd:YAG激光切除牙龈后,观察术后第3个月和第6个月手术刀组和激光组的牙周探诊深度、探诊出血指数以及龈下菌斑DNA提取量,两组无明显区别,表明激光和手术刀远期牙龈效果恢复一样,无显著差别。

SATTARI等[23]在牙周翻瓣术术后监测牙龈愈合情况发现,IL-1β与TGF-β1从基线开始,浓度水平一直在下降。本研究中IL-1β、TGF-β1的浓度水平在术后1周最高,在术后2周下降。可能原因有:① 行牙周翻瓣术的患者,其牙周炎症较行牙龈切除术的患者重,即使所有需要手术的患者在行牙周手术之前均基础治疗,但牙周炎患者的IL-1β、TGF-β1水平仍处于较高的水平。② 两者观察时间不一致,SATTARI的观察时间是术后1个月和术后3个月。③ 两种术式牙周组织所需要恢复的时间不一致。TGF-β1一般存在于牙周手术术后4周和12周。本研究中,术后1周即可在龈沟液中检测出TGF-β1的浓度水平,表明牙龈切除术后,1周内已经有组织在修复。

有研究报道Nd:YAG激光在行牙周手术时,脉冲频率低于引发神经冲动的频率,故术前无须麻醉[24]。有两名受试者因觉疼痛,在术中要求使用麻药,推测可能与受试者存在畏惧心理相关。注射必兰麻后,在激光功率不变的情况下,感觉牙龈切割效果较差。分析原因考虑为必兰麻中含有肾上腺素,具有缩血管作用,Genius激光能被血红蛋白吸收,因而当患者要求使用麻药后,术区局部血管收缩、血红蛋白减少,从而影响激光术中效果。激光组在术后第3天就全部无明显不适,提示与手术刀相比,其在术后引起的疼痛不适感较小,可改善患者术后反应。

在临床上常用于牙龈切除术和牙龈成形术的激光还有二极管激光和CO2激光。二极管激光手术后临床的愈合,已有报道其比手术刀快[24]。但二极管激光对组织造成的热损伤在手术后初级阶段是无法及时消除,会引起更大的炎症反应,因而从组织学上讲,手术刀较二极管激光愈合快[25]。CO2激光可以在局麻下为患者行牙龈切除术和牙龈成形术,具有术野清晰、术后感染率低等优点[26],但该类激光在使用过程中,热效应对组织会造成一定碳化和汽化,临床上观察术区的完全愈合较手术刀推迟2~3周。Genius激光用此类手术,从实验结果中可以看出,术后1周时,牙龈红肿程度明显较手术刀低,并且Genius激光采用冷却的喷雾系统[20],在使用时无异味、无碳化,并可有效降低激光在使用过程中产生的热效应,为患者带来良好的术中和术后舒适感。

参考文献
[1] COBB C M. Lasers in periodontics: a review of the literature[J]. J Periodontol, 2006, 77(4): 545–564. DOI:10.1902/jop.2006.050417
[2] FORNAINI C, ROCCA J P, BERTRAND M F, et al. Nd:YAG and diode laser in the surgical management of soft tissues related to orthodontic treatment[J]. Photomed Laser Surg, 2007, 25(5): 381–392. DOI:10.1089/pho.2006.2068
[3] MAVROGIANNIS M, ELLIS J S, THOMASON J M, et al. The management of drug-induced gingival overgrowth[J]. J Clin Periodontol, 2006, 33(6): 434–439. DOI:10.1111/j.1600-051X.2006.00930.x
[4] CORTES M. Nd:YAG laser-assisted gingivectomy, bleaching, and porcelain laminates, Part 2[J]. Dent Today, 1999, 18(4): 52–55.
[5] EMBERY G, WADDINGTON R. Gingival crevicular fluid: biomarkers of periodontal tissue activity[J]. Adv Dent Res, 1994, 8(2): 329–336. DOI:10.1177/08959374940080022901
[6] HAGENAARS S, LOUWERSE P H, TIMMERMAN M F, et al. Soft-tissue wound healing following periodontal surgery and Emdogain application[J]. J Clin Periodontol, 2004, 31(10): 850–856. DOI:10.1111/j.1600-051X.2004.00571.x
[7] BILLINGHAM M E. Cytokines as inflammatory mediators[J]. Br Med Bull, 1987, 43(2): 350–370. DOI:10.1093/oxfordjournals.bmb.a072187
[8] GRAVES D. Cytokines that promote periodontal tissue destruction[J]. J Periodontol, 2008, 79(8 Suppl): 1585–1591. DOI:10.1902/jop.2008.080183
[9] PULIKKOTIL S J, NATH S. Effect on interleukin-1β and interleukin-8 levels following use of fibrin sealant for periodontal surgery[J]. Aust Dent J, 2014, 59(2): 156–164. DOI:10.1111/adj.12178
[10] RIBAGIN L S, RASHKOVA M R. Matrix metalloproteinase-8 and interleukin-1beta in gingival fluid of children in the first three months of orthodontic treatment with fixed appliances[J]. Folia Med (Plovdiv), 2012, 54(3): 50–56. DOI:10.2478/v10153-011-0097-3
[11] SATTARI M, FATHIYEH A, GHOLAMI F, et al. Effect of surgical flap on IL-1β and TGF-β concentrations in the gingival crevicular fluid of patients with moderate to severe chronic periodontitis[J]. Iran J Immunol, 2011, 8(1): 20–26.
[12] STAHL S S, WITKIN G J, CANTOR M, et al. Gingival healing. Ⅱ. Clinical and histologic repair sequences following gingivectomy[J]. J Periodontol, 1968, 39(2): 109–118. DOI:10.1902/jop.1968.39.2.109
[13] RAMFJORD S, ASH M. Periodontologia e Periodontia: Teoria e Prática Moderna[M]. Sao Paulo: Santos, 1991.
[14] SIGUSCH B, BEIER M, KLINGER G, et al. A 2-step non-surgical procedure and systemic antibiotics in the treatment of rapidly progressive periodontitis[J]. J Periodontol, 2001, 72(3): 275–283. DOI:10.1902/jop.2001.72.3.275
[15] DAMANTE C A, GREGHI S L, SANT'ANA A C, et al. Histomorphometric study of the healing of human oral mucosa after gingivoplasty and low-level laser therapy[J]. Lasers Surg Med, 2004, 35(5): 377–384. DOI:10.1002/lsm.20111
[16] POGREL M A, CHEN J W, ZHANG K. Effects of low-energy gallium-aluminum-arsenide laser irradiation on cultured fibroblasts and keratinocytes[J]. Lasers Surg Med, 1997, 20(4): 426–432. DOI:10.1002/(SICI)1096-9101(1997)20:4<426::AID-LSM8>3.0.CO;2-S
[17] EROGLU C N, TUNÇ S K, ELASAN S. Removal of epulis fissuratum by Er, Cr:YSGG laser in comparison with the conventional method[J]. Photomed Laser Surg, 2015, 33(11): 533–539. DOI:10.1089/pho.2014.3856
[18] JENSEN J, LULIC M, HEITZ-MAYFIELD L J, et al. Nd:YAG (1064 nm) laser for the treatment of chronic periodontitis: a pilot study[J]. J Investig Clin Dent, 2010, 1(1): 16–22. DOI:10.1111/j.2041-1626.2010.00009.x
[19] Karimbux N. Clinical Cases in Periodontics[M]. United States: Wiley-Blackwell, 2012: 69.
[20] 陈春芝, 徐凌, 胡常红, 等. 种植体周围炎龈沟液中SOD、GP-x、MDA水平的初步研究[J]. 重庆医科大学学报, 2015, 40(3): 468–471.
CHEN C Z, XU L, HU C H, et al. Analysis of glutathione peroxidase, superoxide dismutase and malondialdehyde concentration in gingival crevicular fluid in patients with human peri-implantitis[J]. J Chongqing Med Univ, 2015, 40(3): 468–471. DOI:10.13406/j.cnki.cyxb.000594
[21] 杨相笛, 司薇杭, 陈悦, 等. 半导体激光在牙龈切除术及成形术中的应用初探[J]. 陕西医学杂志, 2015, 44(2): 209–211.
YANG X D, SI W H, CHEN Y, et al. Application of semiconductor laser in gingival resection[J]. Shaanxi Med J, 2015, 44(2): 209–211. DOI:10.3969/j.issn.1000-7377.2015.02.031
[22] SHIMIZU N, YAMAGUCHI M, GOSEKI T, et al. Inhibition of prostaglandin E2 and interleukin 1-beta production by low-power laser irradiation in stretched human periodontal ligament cells[J]. J Dent Res, 1995, 74(7): 1382–1388. DOI:10.1177/00220345950740071001
[23] SATTARI M, FATHIYEH A, GHOLAMI F, et al. Effect of surgical flap on IL-1β and TGF-β concentrations in the gingival crevicular fluid of patients with moderate to severe chronic periodontitis[J]. Iran J Immunol, 2011, 8(1): 20–26.
[24] ELANCHEZHIYAN S, RENUKADEVI R, VENNILA K. Comparison of diode laser-assisted surgery and conventional surgery in the management of hereditary ankyloglossia in siblings: a case report with scientific review[J]. Lasers Med Sci, 2013, 28(1): 7–12. DOI:10.1007/s10103-011-1047-2
[25] D'ARCANGELO C, DI NARDO DI MAIO F, PROSPERI G D, et al. A preliminary study of healing of diode laser versus scalpel incisions in rat oral tissue: a comparison of clinical, histological, and immunohistochemical results[J]. Oral and maxillofacial surgery, 2007, 103(6): 764–773. DOI:10.1016/j.tripleo.2006.08.002
[26] PICK R M, PECARO B C, SILBERMAN C J. The laser gingivectomy. The use of the CO2 laser for the removal of phenytoin hyperplasia[J]. J Periodontol, 1985, 56(8): 492–496. DOI:10.1902/jop.1985.56.8.492
http://dx.doi.org/10.16016/j.1000-5404.201704070
中国人民解放军总政治部、国家科技部及国家新闻出版署批准,
由第三军医大学主管、主办

文章信息

甘祎, 黄姣, 白远亮, 张芷玮.
GAN Yi, HUANG Jiao, BAI Yuanliang, ZHANG Zhiwei.
Genius激光与传统手术治疗牙龈增生的术后反应与舒适度临床对比研究
Comparison of postoperative reaction and comfort between Genius laser and traditional surgery for gingival hyperplasia
第三军医大学学报, 2017, 39(19): 1949-1953
Journal of Third Military Medical University, 2017, 39(19): 1949-1953
http://dx.doi.org/10.16016/j.1000-5404.201704070

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收稿: 2017-04-13
修回: 2017-04-17

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